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Clinical Workshop 3: Hernias General Notes: Pubic Tubercle: insertion point of adductor longus Inguinal hernia arise above the inguinal canal (superolateral to pubic tubercle) Femoral hernia arise below the inguinal canal (inferior to pubic tubercle) Clinical Point: “its not where you see them, its where they go back” Hernia: protrusion of an organ through a structure that normally contains it, and occupying another space Deep Inguinal Ring: The deep inguinal ring is a weakness in the transversalis fascia about 1.25 cm above the midpoint of the inguinal ligament and lateral to the inferior epigastric vessels. This is marked by the evagination of the transversalis fascia containing the spermatic cord, as it continues down the inguinal canal as the internal spermatic fascia. The deep inguinal ring allows entrance of structures entering the spermatic cord/ labia majora. Superior Inguinal Ring: The superficial inguinal ring is the most medial part of the inguinal canal and is the small slit like opening between the diagonal fibres of the external oblique, located superolateral to the pubic tubercle, which allows structures like the spermatic cord (males) and round ligament of uterus (females) exit the inguinal canal. The medial and lateral margins are called crura. The medial crus is attached to the pubic tubercle, whilst the lateral crus is attached to the pubic crest. The intercrural fibres running between the crura are such that this slit does not widen further. Hernia: The peritoneal wall protrudes through a neck May cause strangulation blocking off blood supply Some hernias are stuck due to fibrous adhering to other structures All hernia have: occur at same place of congenital weakness most hernias can be REDUCED by pushing the lump back to its origin goes all the way back up to scrotum has an “expansile cough impulse” examination “give me a loud cough” if hernia is present it expands and gets bigger direct hernia comes directly through abdominal wall – medial to inferior epigastric vessels – don’t go all the way to scrotum. The hernial sac is formed by the transversalis fascia due to the evagination. Descends until medial most part of inguinal canal and then through inguinal triangle. Indirect hernia comes through deep inguinal ring – all the way down inguinal canal descends to scrotum covered with evagination of transversalis fascia so hernial sac is formed by persistent processus vaginalis and all three coverings of spermatic fascia superificial inguinal ring Lump Characteristics: Position?, temperature (hot infected), tender (infected), shape, size, tension (soft or hard) faeces, gas or fluid that makes up lumps If lump reduces above and medial to inguinal ligament means inguinal hernia, if below and lateral to inguinal ligament means femoral hernia Signs of Strangulation: Pain acute Fever Signs of gut obstruction o Colociabdomnial pain (very severe pain) o Vomiting o Belly to blow up o Absolute constipation (cant pass wind + faeces) Femoral Hernia: Sometimes extremely difficult to diagnose Most common among females: o Occurs inferolateral to pubic tubercle whilst an indirect inguinal hernia occurs superior to inguinal ligament and enters the scrotum o The femoral ring represents a weakness in anterior abdominal cavity and as a result the hernia originates here, most commonly the loop of small intestine. o Bounded laterally by femoral vein, medially by inferior reflection of inguinal ligament called lacunar ligament o Strangulation occurs very soon must be surgically reduced. This is because the femoral ring is very tight area. Hence the lacunar ligament can be excised to release the pressure on the strangulated tissue (loss of blood supply to parts of small intestine). Otherwise death of tissue may occur. The problem with this procedure is the possibly injury to the obturator artery running very close to this region. o May not have cough impulse due to tightness of area o Very hard to reduce Differential diagnosis: Could be inguinal hernia Saphenovenous dilated veins big lump o Compression possible Abcess tracking down o Normally associated with running a temperature Ectopic testes o Lymph node inflammation Umbilical Hernia o Protrusion through the belly button o Most kids heal up themselves o Common among African children Conclusion From this the following is most important: o Significance of pubic tubercle (above inguinal, below femoral) o Difference between direct and indirect inguinal hernia (direct does not descend to scrotum, indirect descends to scrotum). Clinical Case: Hernia 1 1. Temperature is a little abnormal – 38.5C. Normal for babies is between 37.137.2C. Bp is normal and HR is a little high. Normal range: 150-160bpm. 2. Green Vomit – Bile (duodenum and jejunum up), Sounds – gut obstruction (forced loud sounds) 3. Red, heat, swelling, pain may result in loss of function 4. Hernia – protrusion of a structure through another structure/space that normally contains it. This child is suffering from indirect inguinal hernia because the “mass” extended into the “upper part of the scrotum”. 5. Immediate surgery intervention is required. Prior to surgery, child would be put on fluid resuscitation due to vomit (fluid loss), acid/base balance. Saline is common replacement therapy. 6. Testes descend during embryological development Clinical Case: Hernia 2 1. This patient is suffering from direct inguinal hernia. The lump enlarges during coughing because we are increasing intra-abdominal pressure and as a result we are forced the structure to move during the process. When lying down, the structure is under less pressure, therefore moving back into the superficial inguinal ring. 2. The lump is above the pubic tubercle. Hence this must a type of inguinal hernia. The lump is also said to be medial to the inferior epigastric vessels, which narrows it down to “DIRECT INGUINAL HERNIA”. 3. Inferior inguinal ligament, Superolateral inferior epigastric vessels, Medial lateral edge of Rectus Abdominis. Clinical Case: Hernia 3 1. The lump is below the pubic tubercle hence must be femoral hernia. Femoral hernias normally occur inferolateral to the pubic tubercle. A femoral hernia pass through the femoral ring, which is a weakness in the anterior abdominal cavity. The hernia is bounded laterally by the femoral vein, medially by the lacunar ligament (reflection of the inguinal ligament). Hernia then descends into the saphenous opening, into the subcutaneous tissue. The saphenous opening lies in the femoral triangle, which is bounded laterally by the medial border of sartorius, medially by lateral border of adductor longus, superiorly by inferior portion of inguinal ligament. 2. The opening is called saphenous opening, this is where the great saphenous vein drains into the femoral vein. The hernia now passes into the cribiform fascia which covers the saphenous opening. 3. Femoral hernia can become strangulated. As a result blood supply to the hernial structure can be diminished and as a result causes tissue death. This causes pain.